Telehealth FAQ

Executive Order↓

What does the Executive Order D 2020 027 banning elective and non-emergency procedures apply to?

The order applies to medical, dental, and veterinary procedures deemed voluntary or elective, meaning that the surgery or procedure can be delayed for a minimum of three months without undue risk to the current or future health of the patient as determined by the guidelines developed by the hospital, surgical center or other treating medical facility. SOURCE

What does the Executive Order D 2020 027 banning elective and non-emergency procedures NOT apply to?

The order does not apply when the following conditions are present: There is a threat to the patient’s life if the surgery or procedure is not performed; There is a threat of permanent dysfunction of an extremity or organ system if the surgery or procedure is not performed; There is a risk of metastasis or progression of staging of a disease or condition if the surgery or procedure is not performed; or There is a risk that the patient's condition will rapidly deteriorate if the surgery or procedure is not performed and there is a threat to life, or to an extremity or organ system, or of permanent dysfunction or disability. SOURCE

Who does the Executive Order D 2020 027 banning elective and non-emergency procedures apply to?

The order applies to professionals that work within a hospital, office, clinic, or practice in the medical, dental, or veterinary fields. More specifically, to all of those whom it applies, the aforementioned criteria for providing lifesaving and critical services needs to be assessed. DORA-licensed professionals that need to be diligent about compliance with the order include, but are not limited to Acupuncturists, Audiologists, Chiropractors, Dentists, Dental Hygienists, Hearing Aid Providers, Massage Therapists, Naturopathic Doctors, Nurses, Occupational Therapists, Optometrists, Podiatrists, Physicians, Physical Therapists, Respiratory Therapists, Speech-Language Pathologists, Surgical Assistants, and Veterinarians. The state respects the doctor/patient relationship, and understands if procedures need to be conducted to prevent further deterioration or loss of life. However, the intent of this order is to free up personal protective equipment (PPE) and ventilators so that they are available to those professionals working on the front lines of the epidemic. Further,the state strongly recommends all licensed professionals adhere to CDPHE’s guidance regarding social distancing. Under this guidance, individuals are advised not to interact unless they can maintain a six-foot distance to prevent the spread of the virus. Contact between practitioners and clients should be limited to essential services only because all non-essential contact heightens the risk of spreading the virus. In short, we ask that all health care professionals remain acutely conscientious about the procedures being conducted to ensure that they support overall public health, wellness, and welfare during this challenging time. SOURCE

Who does the Executive Order D 2020 027 banning elective and non-emergency procedures NOT apply to?

Medical professionals at rural and critical access hospitals are exempt from this Order, but are strongly advised to comply on a voluntary basis, and must still comply with CDC guidelines for PPE preservation. Although exempt, we encourage an assessment of providing lifesaving and critical services to an effort to preserve resources. Rural hospitals are defined as hospitals located in a non-metropolitan county or hospitals within a metropolitan county that are far away from the urban center, as defined by a rural urban community area code of four or above (HRSA 2017). Critical Access Hospital is a designation given to eligible rural hospitals by the Centers for Medicare and Medicaid Services (CMS) under the provisions of the Balanced Budget Act of 1997. SOURCE

Policy↓

What are the COVID-19 State of Emergency Changes to Telemedicine Services?

Department of Healthcare Policy and Financing is authorizing three temporary changes to the existing telemedicine policy:

1. Telephone and Live Chat Modalities - Providers may deliver the allowable telemedicine services by telephone or via live chat and no longer be restricted to an interactive audiovisual modality only. All other general requirements for telemedicine services, such as documentation and meeting the same standard of care still need to be met.

2. Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services - For the duration of the COVID-19 state of emergency, Health First Colorado is allowing telemedicine visits to qualify as billable encounters. Services allowed under telemedicine may be provided via telephone, live chat, or interactive audiovisual modality for these provider types.

3. Physical Therapy, Occupational Therapy, Home Health, Hospice and Pediatric Behavioral Health Providers - Health First Colorado has expanded the list of providers eligible to deliver telemedicine services. Services delivered by these provider types require an interactive audiovisual connection to the member; they cannot be provided using telephone or live chat. SOURCE

What does the new adoption of Emergency Regulation 20-E-05 concerning coverage and reimbursement for telehealth services during COVID-19 disaster emergency mean?

The purpose of this emergency regulation is to require carriers to reimburse providers for provision of telehealth services using non-public facing audio or video communication products during the COVID-19 nationwide public health emergency.

On March 17, 2020, the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced that it will waive potential Health Insurance Portability and Accountability Act (HIPAA) penalties for good faith use of telehealth during the nationwide public health emergency due to COVID-19. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19.

On March 11, 2020, Governor Polis issued Executive Order D 2020 003 declaring a disaster emergency due to the presence of COVID-19 in Colorado. On April 1, 2020, Governor Polis issued Executive Order D 2020 020 (“Order”) ordering the temporary suspension of certain provisions of § 10-16-123, C.R.S., to expand the use of telehealth, whenever possible, to protect the public health and mitigate exposure to and the spread of COVID-19. The Order authorizes the Commissioner of Insurance to adopt emergency regulations related to telehealth during the COVID-19 public health emergency. This regulation shall remain in effect for 120 days or as long as the Governor’s Emergency Declaration is in effect, whichever is shorter.

The Division of Insurance finds, pursuant to § 24-4-103(6)(a), C.R.S., that immediate adoption of this regulation is imperatively necessary for the preservation of public health, safety, or welfare as allowing individuals broader access to telehealth services during the COVID-19 public emergency is imperative to preserve the health of the citizens of Colorado. Therefore, compliance with the requirements of § 24-4-103, C.R.S., would be contrary to the public interest. SOURCE

Consent↓

Payers have loosened billing restrictions and are allowing more services to be provided by phone. Is consent for Telehealth required for services by phone or just when provided by video and audio?

The new HCPF waiver states that providers must document the member’s consent, either verbal or written, to receive telemedicine services for any modality. SOURCE

What constitutes a valid patient consent signature?

Providers must document the member’s consent, either verbal or written, to receive telemedicine services. SOURCE

Prior Authorization↓

Will new/existing Prior Authorization Requests require telemedicine Place of Service 02 to be indicated?

No. The Place of Service field in the request does not need to be populated. SOURCE

Will new or existing Prior Authorization Requests require modifier GT to be indicated?

No. Modifier GT does not need to be on the Prior Authorization Request for it to be billed on a claim. SOURCE

Billing↓

What are the billing practices for providers to receive reimbursement for telemedicine services?

UB-04 Institutional Claims - Providers must indicate that the service(s) were provided through telemedicine by appending modifier GT to the UB-04 institutional claim form with the service's usual billing codes. This identifies the service as provided via telemedicine during the COVID-19 State of Emergency. CMS 1500 Professional Claims - Place of Service code 02 must be indicated on all CMS 1500 professional claims for telemedicine. Only specific CPT/HCPCS are allowed.

How do I bill for telemedicine services?

A single provider may bill a service with Place of Service 02, for professional claims, when the member is not physically present in the provider’s office and services are rendered through telemedicine. See the coding table below. Place of Service 02 (Telehealth) should be used for all telemedicine visits.

When two providers are involved, one provider can be reimbursed as the "originating provider" where the member is present with the provider at the "originating site" and that originating provider is consulting with a "distant provider". Another provider can also be reimbursed as a "distant provider" for any covered Telemedicine Services.

Should we list the physical address of the originating or distant site when we are billing for the distant site provider? Is there a standard regulation, or actual variation between payers?

CPT codes for billing are different based on patient location. So yes, physical address should be listed as a general rule. It is also an ATA recommended best practice for documenting physician and patient location. SOURCE

Are there simple billing and coding instructions for staff in particular around services by phone?

SOURCE and SOURCE These are sources to refer to. A simple guide is in progress.

Why is hospital based billing more challenging then private practice in regards to telehealth?

The hospital or entity may or may not have a provider ID. A provider ID is required to bill for telehealth services. This is why billing typically goes through a separate provider group from the hospital.

For the reimbursement that we are seeing, are copays being paid by insurance?

Member cost share for Telehealth consults for COVID-19 are waived across the board for all major carriers: CIGNA, UHC, CVS/Aenta, Anthem, & Humana. The assumption is that the carrier is covering the cost on behalf of members.

All Providers (general)↓

Can providers bill HCPCS Q3014 when the provider is delivering the care from a clinical setting?

Q3014 should be billed by a provider at the originating site. The originating site is the location of the patient at the time the service is being furnished via a telemedicine modality. If the member is not physically present at the site, then the Q3014 code would not be appropriate.

For providers other than FQHCs: If a patient receives a covered service and also is connected with a distant provider via telemedicine during the visit, then Q3014 may be billed in addition to the services provided during that visit.

For FQHCs: If a patient is at an FQHC and receives a covered service and also is connected with a distant provider via telemedicine, the FQHC can only submit a claim for an encounter. All services provided during the visit are included in the encounter payment and that would include Q3014. The only way an FQHC would receive the Q3014 payment is if there is no payable encounter for the patient on that day. SOURCE

Can providers work from home (e.g. Dr. is quarantined) but still provide telemedicine services?

Yes. The distant provider may participate in the telemedicine interaction from any appropriate location. SOURCE

If my patient has private insurance (third party liability, TPL) that doesn't cover the telemedicine visit, will Health First Colorado (Colorado Medicaid) still cover it?

Yes. Standard TPL policy still applies. See the General Provider Manual for details. SOURCE

Is modifier GT required to be on a claim for telemedicine-delivered services?

For CMS1500 claim types, modifier GT is not required. It can optionally be used for certain codes that are indicated in the telemedicine billing manual. Modifier GT gives extra payment for certain codes.

For UB-04 claim types, modifier GT is required for Home Health Agencies, Hospice, Federally Qualified Health Centers, Rural Health Clinics, and Outpatient Hospitals. Modifier GT should be appended to each line item that was performed via telemedicine. Indian Health Services providers should refer to specific guidance elsewhere in the FAQ. SOURCE

Are providers able to see new patients through telemedicine?

Yes, new regulations have loosened these restrictions SOURCE

Indian Health Services↓

Is modifier GT required to be on a claim for telemedicine-delivered services?

No. Appending modifier GT to a line item is optional but encouraged. SOURCE

Do telephone-only visits qualify as an encounter claim submission?

Yes. SOURCE

Physical, Occupational, and Speech Therapy↓

Can therapy assistants provide telemedicine?

Yes; however DORA supervision rules are still applicable to telemedicine visits. SOURCE

Behavioral Health↓

Aside from Consent for Telehealth (video/audio), are there additional agreements or disclosures that should be made for groups?

• Consent to treatment
• Consent for group therapy
• HIPAA agreement
• Group confidentiality agreement
• Group therapy guidelines and rules
• Patient rights
• Provider duties
• Other facility specific document

Are there group facilitation "best practices" (having everyone introduce themselves to know who is "in the room")?

SOURCE Very large document and is specific to psychotherapy. However this is a popular reference for group therapy set ups. Pro tip: All relevant info are in the bullet points and summary statements

Are there group security "best practices" to protect personal phone numbers (of both staff and participants) during video groups?

From what we understand most physicians are using a second phone number. However most platforms (including Zoom) have an option to hide the caller ID and numbers. Google Voice also provides free phone numbers that can be used to mask a person’s actual phone number.

Have others done group therapy via telehealth? If so, any lessons learned we can pull from? Resources or guide for clinicians about best practices before/during/after group? Are there therapeutic scripts/templates that others have developed that would be useful for introductions, disclaimers, troubleshooting etc.?

Plenty of behavioral health group therapy work has been done via telehealth. Most of them are reported in literature. SOURCE outlines lessons learnt etc and SOURCE guide for clinicians

Rural Health↓

Are federally certified Rural Health Clinics allowed to bill for telehealth as a distant site for Medicare?

Yes, the Federal government has passed the third in a series of bills in response to COVID-19. In Sec. 3704. Allowing Federally Qualified Health Centers and Rural Health Clinics to Furnish Telehealth in Medicare: This section allows, during the COVID-19 emergency period, Federally Qualified Health Centers and Rural Health Clinics to serve as a distant site for telehealth consultations. A distant site is where the practitioner is located during the time of the telehealth service. This section allows FQHCs and RHCs to furnish telehealth services to beneficiaries in their home. Medicare would reimburse for these telehealth services based on payment rates similar to the national average payment rates for comparable telehealth services under the Medicare Physician Fee Schedule. It also excludes the costs associated with these services from both the FQHC prospective payment system and the RHC all-inclusive rate calculation. SOURCE (Page 136)

Prescribing↓

What is the Colorado Application of DEA Guidance Regarding Oral Schedule II Controlled Substance Prescriptions?

The Drug Enforcement Administration (DEA) provided guidance and temporary exceptions regarding the issuance of oral schedule II controlled substance prescriptions in light of the nationwide public health emergency prompted by the COVID-19 pandemic. The DEA recognized obstacles the pandemic has created for practitioners in their ability to meet with existing patients and provide written schedule II prescriptions. SOURCE

However, Colorado prescribers and pharmacists must adhere to the stricter set of two laws between the DEA and Article 18 of the Colorado Uniform Controlled Substance Act of 2013. To this end, Colorado Law (section 18-18-414(2)(a), C.R.S.) mandates, in summary, the following:

1. A pharmacist may dispense no greater than a 72-hour supply of a schedule II controlled substance to a patient in an emergency situation pursuant to a telephonic order from a prescriber.

2. The corresponding prescriber must then reduce the order to writing or electronic (electronic prescribing) format and shall deliver the order to the dispensing pharmacy by either electronic (electronic prescribing), facsimile, or mail (or have postmarked for mail delivery) within 72 hours of issuing the emergency telephonic order. SOURCE

General Telehealth↓

What is telehealth?

The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration. Technologies include videoconferencing, the internet, store- and-forward imaging, streaming media, and landline and wireless communications.

Telehealth services may be provided, for example, through audio, text messaging, or video communication technology, including video conferencing software. For purposes of reimbursement, certain payors, including Medicare and Medicaid, may impose restrictions on the types of technologies that can be used.1 Those restrictions do not limit the scope of the HIPAA Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications. SOURCE

What are the requirements for telehealth services?

1. The reimbursement rate, as a minimum, will be set at the same rate as the medical assistance program rate for a comparable in-person service.
2. Providers may only bill procedure codes which they are already eligible to bill.
3. Any health benefits provided through telemedicine shall meet the same standard of care as in-person care.
4. Providers must document the member’s consent, either verbal or written, to receive telemedicine services.
5. The availability of services through telemedicine in no way alters the scope of practice of any health care provider; nor does it authorize the delivery of health care services in a setting or manner not otherwise authorized by law.
6. Services not otherwise covered by Health First Colorado are not covered when delivered via telemedicine. The use of telemedicine does not change prior authorization requirements that have been established for the services being provided.
7. Record-keeping and patient privacy standards should comply with normal Medicaid requirements and HIPAA. Office for Civil Rights (OCR) Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency SOURCE

What is a “non-public facing” remote communication product?

A “non-public facing” remote communication product is one that, as a default, allows only the intended parties to participate in the communication. Non-public facing remote communication products would include, for example, platforms such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Whatsapp video chat, or Skype. Such products also would include commonly used texting applications such as Signal, Jabber, Facebook Messenger, Google Hangouts, Whatsapp, or iMessage. Typically, these platforms employ end-to-end encryption, which allows only an individual and the person with whom the individual is communicating to see what is transmitted. The platforms also support individual user accounts, logins, and passcodes to help limit access and verify participants. In addition, participants are able to assert some degree of control over particular capabilities, such as choosing to record or not record the communication or to mute or turn off the video or audio signal at any point.

In contrast, public-facing products such as TikTok, Facebook Live, Twitch, or a chat room like Slack are not acceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide or indiscriminate access to the communication. For example, a provider that uses Facebook Live to stream a presentation made available to all its patients about the risks of COVID-19 would not be considered reasonably private provision of telehealth services. A provider that chooses to host such a public-facing presentation would not be covered by the Notification and should not identify patients or offer individualized patient advice in such a livestream. SOURCE

Where can health care providers conduct telehealth?

OCR expects health care providers will ordinarily conduct telehealth in private settings, such as a doctor in a clinic or office connecting to a patient who is at home or at another clinic. Providers should always use private locations and patients should not receive telehealth services in public or semi-public settings, absent patient consent or exigent circumstances.

If telehealth cannot be provided in a private setting, covered health care providers should continue to implement reasonable HIPAA safeguards to limit incidental uses or disclosures of protected health information (PHI). Such reasonable precautions could include using lowered voices, not using speakerphone, or recommending that the patient move to a reasonable distance from others when discussing PHI. SOURCE

HIPAA Notification of Enforcement Discretion↓

What entities are included and excluded under the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications?

The Notification of Enforcement Discretion issued by the HHS Office for Civil Rights (OCR) applies to all health care providers that are covered by HIPAA and provide telehealth services during the emergency. A health insurance company that pays for telehealth services is not covered by the Notification of Enforcement Discretion. Under the Health Insurance Portability and Accountability Act (HIPAA), a “health care provider” is a provider of medical or health services and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business. Health care providers include, for example, physicians, nurses, clinics, hospitals, home health aides, therapists, other mental health professionals, dentists, pharmacists, laboratories, and any other person or entity that provides health care. A “health care provider” is a covered entity under HIPAA if it transmits any health information in electronic form in connection with a transaction for which the Secretary has adopted a standard (e.g., billing insurance electronically). See 45 CFR 160.103 (definitions of health care provider, health care, and covered entity). By contrast, a health insurance company that merely pays for telehealth services would not be covered by the Notification of Enforcement Discretion because it is not engaged in the provision of health care. SOURCE

What patients can a covered health care provider treat under the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications and does it include Medicare and Medicaid patients?

This Notification applies to all HIPAA-covered health care providers, with no limitation on the patients they serve with telehealth, including those patients that receive Medicare or Medicaid benefits, and those that do not. Information specifically about telehealth and Medicare is available HERE and HERE.

Which parts of the HIPAA Rules are included in the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications?

Covered health care providers will not be subject to penalties for violations of the HIPAA Privacy, Security, and Breach Notification Rules that occur in the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This Notification does not affect the application of the HIPAA Rules to other areas of health care outside of telehealth during the emergency. SOURCE

Does the Notification of Enforcement Discretion regarding COVID- 19 and remote telehealth communications apply to violations of 42 CFR Part 2, the HHS regulation that protects the confidentiality of substance use disorder patient records?

No, the Notification addresses the enforcement only of the HIPAA Rules. The Substance Abuse and Mental Health Services Administration (SAMHSA) has issued similar guidance on COVID-19 and 42 CFR Part 2, which is available HERE SOURCE.

When does the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications expire?

The Notification of Enforcement Discretion does not have an expiration date. OCR will issue a notice to the public when it is no longer exercising its enforcement discretion. SOURCE

What telehealth services are covered by the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications?

All services that a covered health care provider, in their professional judgement, believes can be provided through telehealth in the given circumstances of the current emergency are covered by this Notification. This includes diagnosis or treatment of COVID-19 related conditions, such as taking a patient’s temperature or other vitals remotely, and diagnosis or treatment of non-COVID-19 related conditions, such as review of physical therapy practices, mental health counseling, or adjustment of prescriptions, among many others. SOURCE

What may constitute bad faith in the provision of telehealth by a covered health care provider, which would not be covered by the Notification of Enforcement Discretion regarding COVID-19 and remote telehealth communications?

OCR would consider all facts and circumstances when determining whether a health care provider’s use of telehealth services is provided in good faith and thereby covered by the Notice. Some examples of what OCR may consider a bad faith provision of telehealth services that is not covered by this Notice include:

Conduct or furtherance of a criminal act, such as fraud, identity theft, and intentional invasion of privacy; Further uses or disclosures of patient data transmitted during a telehealth communication that are prohibited by the HIPAA Privacy Rule (e.g., sale of the data, or use of the data for marketing without authorization); Violations of state licensing laws or professional ethical standards that result in disciplinary actions related to the treatment offered or provided via telehealth (i.e., based on documented findings of a health care licensing or professional ethics board); or Use of public-facing remote communication products, such as TikTok, Facebook Live, Twitch, or a chat room like Slack, which OCR has identified in the Notification as unacceptable forms of remote communication for telehealth because they are designed to be open to the public or allow wide or indiscriminate access to the communication. SOURCE

If a covered health care provider uses telehealth services during the COVID-19 outbreak and electronic protected health information is intercepted during transmission, will OCR impose a penalty on the provider for violating the HIPAA Security Rule?

No. OCR will exercise its enforcement discretion and will not pursue otherwise applicable penalties for breaches that result from the good faith provision of telehealth services during the COVID-19 nationwide public health emergency. OCR would consider all facts and circumstances when determining what constitutes a good faith provision of telehealth services. Providers seeking to use video communication products are encouraged to use such vendors that will protect ePHI by signing a HIPAA business associate agreement (BAA), but will not be penalized for using less secure products in their effort to provide the most timely and accessible care possible to patients during the Public Health Emergency. Providers are encouraged to notify patients that third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. SOURCE

Electronic communications↓

Should we make electronic communications a mode of service delivery in the EHR so this time can be counted too?

There is a "telephone call" mode of delivery in most EHRs. Changing that to electronic communications mode could possibly be helpful though not urgent. Note that the mode of service needs to be linked to billing so that the provider can bill for services provided via e-communications.

Copies of Documents↓

Is there guidance or recommendations on workflows for providing copies of documents to patients? Is it adequate/appropriate to ask if they want a copy when we’re able to resume “normal” services?

Put a bank of standard, blank versions of forms on the website. Email or text patients links to the forms on the website letting them know this is what they verbally consented to. You have up to 30 days to provide the patient with a copy (per source link), so may also want to consider mailing a paper version to the patient’s house if necessary, or doing batch sends weekly or monthly in a more manageable workflow. SOURCE